NOTICE: AUTOMOBILE ACCIDENT PATIENTS

If you have been in an automobile accident, you may be entitled to payment from your automobile insurance if you have medical expense benefits coverage.  By signing this assignment of benefits form, you are giving to your health care provider the right to receive some or all of the payment directly from your automobile insurance company.

If you have health insurance and your healthcare provider is in-network:   As long as you provide information necessary to verify your health insurance coverage, the healthcare provider may only bill the amount you owe for any co-payment, coinsurance, or deductibles to your automobile insurance and you may be entitled to any remainder of your automobile insurance benefit.

If you do not provide information necessary to verify your health insurance coverage, do not have health insurance, or your healthcare provider is not in your health insurer’s provider network, your healthcare provider may bill its full charges to your automobile insurance.

You may want to consult your insurance agent or attorney before signing or initialing this form.  You are not required to sign/initial this form to receive care.  However, if you do not sign this form, you will be required to (i) pay any applicable co-pays and deductibles at the time the services are provided and allow us to bill your health insurance company or (ii) pay for all care at the time of service.

By signing below, I acknowledge that I have read or had the opportunity to read this notice.